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 Health Policy

Pandemic preparedness and response: exploring the role of

universal health coverage within the global health security
architecture
Arush Lal, Salma M Abdalla, Vijay Kumar Chattu, Ngozi Adaeze Erondu, Tsung-Ling Lee, Sudhvir Singh, Hala Abou-Taleb, Jeanette Vega Morales,
Alexandra Phelan

In response to the COVID-19 pandemic, several international initiatives have been developed to strengthen and reform Lancet Glob Health 2022;
the global architecture for pandemic preparedness and response, including proposals for a pandemic treaty, a Pandemic 10: e1675–83

Fund, and mechanisms for equitable access to medical countermeasures. These initiatives seek to make use of crucial Published Online
September 27, 2022
lessons gleaned from the ongoing pandemic by addressing gaps in health security and traditional public health
https://doi.org/10.1016/
functions. However, there has been insufficient consideration of the vital role of universal health coverage in sustainably S2214-109X(22)00341-2
mitigating outbreaks, and the importance of robust primary health care in equitably and efficiently safeguarding Department of Health Policy,
communities from future health threats. The international community should not repeat the mistakes of past health London School of Economics
security efforts that ultimately contributed to the rapid spread of the COVID-19 pandemic and disproportionately and Political Science, London,
UK (A Lal MSc); Department of
affected vulnerable and marginalised populations, especially by overlooking the importance of coherent, multisectoral
Epidemiology, Boston
health systems. This Health Policy paper outlines major (although often neglected) gaps in pandemic preparedness University School of Public
and response, which are applicable to broader health emergency preparedness and response efforts, and identifies Health, Boston, MA, USA
opportunities to reconceptualise health security by scaling up universal health coverage. We then offer a comprehensive (S M Abdalla MBBS DrPH);
Center for Interdisciplinary
set of recommendations to help inform the development of key pandemic preparedness and response proposals across
Research, Saveetha Institute of
three themes—governance, financing, and supporting initiatives. By identifying approaches that simultaneously Medical and Technical Sciences,
strengthen health systems through global health security and universal health coverage, we aim to provide tangible Saveetha University, Chennai,
solutions that equitably meet the needs of all communities while ensuring resilience to future pandemic threats. India (V K Chattu MD MPH);
Department of Community
Medicine, Faculty of Medicine,
Introduction have long been off-track. Where progress on UHC had Datta Meghe Institute of
The health and wellbeing of populations worldwide are been made, the focus has largely been on expanding Medical Sciences, Wardha,
at a pivotal, yet precarious, moment. Although the financial coverage through health insurance rather than India (V K Chattu); Department
of Occupational Science and
COVID-19 pandemic unveiled health inequities and ensuring available, accessible, acceptable, and high-
Occupational Therapy, Temerty
exposed striking weaknesses in pandemic preparedness quality health services.5 Few countries had invested in Faculty of Medicine, University
and response, our collective failure to build resilient and integrated health systems that were equipped to support of Toronto, Toronto, ON,
responsive health systems that meet the needs of all both global health security and UHC.6 Canada (V K Chattu); O’Neill
Institute for National and
should have come as no surprise. These weaknesses go Health systems can be considered as the means by Global Health Law,
beyond pandemic preparedness and response, and also which health priorities, including global health security Georgetown University Law
apply to health emergency preparedness and response and UHC, can be operationalised. Strengthening of Center, Washington, DC, USA
more broadly.1 The rapid spread of the COVID-19 health systems is a necessary component of epidemic (N A Erondu PhD, A Phelan SJD);
Global Health Institute for
pandemic simply underscored long-existing gaps and and pandemic preparedness and response, supporting Disease Elimination, United
bottlenecks in the global health security architecture that essential public health functions including robust health Arab Emirates Global Health
impeded public health systems from preventing, infrastructure, trained and protected health-care workers, Programme, Chatham House,
detecting, and responding to international infectious adequate funding, reliable supply chains, and evidence- London, UK (N A Erondu);
Graduate Institute of Health
disease threats. Health systems were further weakened based planning and coordination. Effective and accessible and Biotechnology Law, Taipei
by chronic underinvestments in national and subnational primary health care can be a key approach for creating Medical University, Taipei,
health systems over the years, including inadequate cohesion between global health security and UHC. Taiwan (T-L Lee SJD);
mechan­isms for real-time epidemiological surveillance Primary health care is the range of people-centred Department of Epidemiology
and Biostatistics, Faculty of
and monitoring during health emergencies.2 essential health services and goods that support the Medical and Health Sciences,
Universal health coverage (UHC) is an equally majority of a person’s health needs over their lifetime. University of Auckland,
important, although often overlooked, element in Previous studies contend that the lack of adequate Auckland, New Zealand
preventing health emergencies. Although UHC is primary health care might have jeopardised the ability of (S Singh MBChB); Health
System Governance Team,
technically focused on mitigating the financial burden countries to mount an equitable response to COVID-19 Department of Universal
of health care, it has often been used to describe the or ensure resilience in the face of complex, competing Health Coverage/Health
wider set of interventions necessary to ensure that health and economic crises.7 Systems, Regional Office for
the Eastern Mediterranean,
all people have access to comprehensive health Several initiatives have been launched in the wake
World Health Organization,
services. International commitments to achieve UHC, of COVID-19 to better prepare for and respond to both Cairo, Egypt
strengthened through the UN Sustainable Development the current pandemic and future health threats. (H Abou-Taleb MD DrPH);
Goal (SDG) 3.8 target to achieve UHC3 and the political Three major reports recommended revisions to the Ministry of Social Development
and Family, Santiago, Chile
declaration of the UN High-Level Meeting on UHC,4 international governance of global health security,

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 Health Policy

such as improving compliance with the International

Key messages Health Regulations (IHR, 2005) and supporting a new
Key challenges in pandemic preparedness and response international instrument for pandemic preparedness and
• Over-reliance on global health security interventions at the expense of universal health response.2,8,9 The Working Group on Strengthening WHO
coverage (UHC) Preparedness and Response to Health Emergencies was
• Gaps in mitigating socioeconomic factors and wider determinants of health tasked with reviewing the findings of these reports and to
• Lack of inclusive and equitable engagement mechanisms in public health decision explore implications for pandemic preparedness and
making response.10 Other initiatives included G20-led discussions
for multilateral mechanisms to better finance health
Recommendations to strengthen pandemic preparedness and response emergency preparedness and response, including a
Governance Global Health Threats Fund and Global Health Threats
• Include explicit commitments to address UHC and broader health systems gaps in all Board.2,11 The Access to COVID-19 Tools (ACT) Accelerator,
legislation and policy reforms related to pandemic preparedness and response (eg, launched at the start of the pandemic to ensure equitable
pandemic treaty and International Health Regulations [IHR] amendments) access to medical countermeasures, has been proposed as
• Base future pandemic preparedness and response efforts on a human rights approach a model for a pre-negotiated system to enable rapid
• Ensure multistakeholder and multisectoral engagement at all stages of policy response in future outbreaks, in conjunction with
development accountability mechanisms, including the Universal
• Encourage political leadership to strengthen health systems to mitigate health Health and Preparedness Review.12 High-level political
emergencies (eg, through the Global Health Threats Council and the UN High-Level leadership on pandemic preparedness and response has
Meeting) been envisioned through proposals for a Global Health
• Strengthen national and global accountability for pandemic preparedness and Threats Council and UN Political Declaration on
response through joint assessments (eg, Universal Health and Preparedness Review) pandemic prevention, preparedness, and response via the
• Prevent exclusion of stakeholders from low-income countries and other marginalised UN General Assembly,13 opening new avenues for
groups (eg, women, racial minorities, and patient advocates) from the global health geopolitical, multisectoral engagement to address broader
security architecture public health challenges.14 Although these proposals offer
Financing crucial opportunities to meaning­fully shape the future of
• Integrate investments in health systems to strengthen capacity of both global health pandemic preparedness and response, there is increasing
security and UHC concern that such mechanisms will ultimately not
• Ensure all financial mechanisms for pandemic preparedness and response (eg, address fragmentation in health systems, inequity in
Pandemic Fund) receive a minimum base amount of financing to sustain community- health governance, and poor accountability in pandemic
based health system capacities during emergencies (eg, health workers and essential preparedness and response. Such a result would leave us
health services) unprepared for not only the next pandemic, but all health
• Address social determinants of health through financing for pandemic preparedness crises we have yet to face.
and response Here, we identify three major challenges that threaten
• Foster global solidarity and alignment for pandemic preparedness and response the success of pandemic preparedness and response
investments (eg, common goods for health, WHO-assessed contributions, and linkages initiatives proposed in the wake of the COVID-19
between IHR benchmarks and pandemic treaty) pandemic: (1) fragmented approaches to public health
• Expand domestic and regional financing for pandemic preparedness and response and outbreak response, including an over-reliance on
capacities tied to primary health care global health security at the expense of UHC; (2) weak
Supporting initiatives health systems that are unable to address inequities
• Incorporate UHC approaches in all disease-specific health security programmes amid the fragility of highly interconnected economies
• Establish standing country coordination teams for health systems to support and social systems; and (3) inadequate engagement
emergency response and recovery (eg, through national IHR focal points) of key stakeholders, resulting in a lack of trust in
• Apply a holistic definition of health equity and the right to health in future pandemic public health institutions and decision makers. We then
preparedness and response mechanisms (eg, through future iterations of the Access to identify emerging opportunities for integration between
COVID-19 Tools Accelerator or the WHO Global Health Emergency Council) global health security and UHC through strengthening
• Support nationally identified priorities in health systems resilience through donor- of health systems, in particular primary health care, and
driven health security programmes (eg, the Global Health Security Agenda; the US propose recommendations for a more cohesive, resilient,
President’s Emergency Plan for AIDS Relief; the Global Fund to Fight AIDS, Tuberculosis and responsive pandemic preparedness and response
and Malaria; or Gavi, the Vaccine Alliance) architecture.
• Align diverse frameworks used to guide coherent, sustainable pandemic preparedness
and response initiatives (eg, WHO white paper on health emergency preparedness and Major challenges in pandemic preparedness and
response architecture) response
Over-reliance on global health security
The progression of the COVID-19 pandemic
suggests that hyperfocusing only on infectious disease
response can distort the overall reality: health systems

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worldwide are chronically underfunded, disjointed, and COVID-19 symptoms, and availability of intensive care (J Vega Morales MD DrPH);
inequitable.15,16 Investments in early-warning systems units was considerably reduced among poor and Black Center for Global Health
Science and Security,
and advanced laboratories are undoubtedly needed, communities.29 In the USA, racial and socioeconomic Georgetown University
such as through initiatives like the WHO Hub for disparities were reported in COVID-19 infection and Medical Center, Washington,
Pandemic and Epidemic Intelligence. However, these death rates; marginalised groups also experienced DC, USA (A Phelan)
investments will not be sufficient unless concretely tied barriers in accessing prevention and treatment. Income Correspondence to:
to broader initiatives that strengthen health systems and disparities have been reflected in the scarcity of beds in Arush Lal, Department of Health
Policy, London School of
are supported by UHC.17 For example, in the first intensive care units, particularly in rural areas.30
Economics and Political Science,
6 months of the COVID-19 pandemic, about 90% of London WC2A 2AE, UK
countries reported disruptions to essential health A lack of inclusive and equitable engagement [email protected]
services, and many individuals were unable to access mechanisms For more on WHO Hub for
nearby health centres or afford testing.18,19 These Because global response to health emergencies is Pandemic and Epidemic
Intelligence see
disruptions can largely be attributed to inadequate primarily coordinated at the nation-state level, the absence
https://pandemichub.who.int
progress on UHC and poor consideration of the role of of engagement from local communities and civil societies
primary health care in preparedness and response. Less undermines equitable governance that represents all
than half of the countries in one major analysis included perspectives.31,32 Although these issues have been well
the maintenance of health services in their national documented even before the pandemic, they risk being
COVID-19 strategic plans,20 and chronic distrust of further exacerbated in the wake of the COVID-19
health-care providers impeded the response in many pandemic,33 because an increasing focus on strengthening
communities.21 WHO reported that up to 180 000 health global health security initiatives tends to sideline much
and care workers might have died from COVID-19 in needed investment in UHC. Meanwhile, global
the period between January, 2020, and May, 2021, often administrations pursued a particular notion of equity by
from poor working conditions, while inadequate focusing solely on addressing inequitable access to
planning and workforce capacity led to the destruction medical countermeasures among countries (eg, vaccine
of hundreds of thousands of vaccine doses in high- equity) but overlooked in-country disparities in delivering
income and low-income countries alike.22,23 These issues life-saving COVID-19 supplies and maintaining routine
go beyond the scope of traditional global health security health services.34
and offer a cautionary tale about the pitfalls of neglecting These challenges can be addressed by improving whole-
primary health care, underpinned by commitments to of-society representation in health systems as a core
UHC, in future pandemic preparedness and response component of future pandemic preparedness and
initiatives. response initiatives. Leveraging diverse, multistakeholder
governance is a key factor for better delivering UHC-
Gaps in mitigating socioeconomic factors related interventions.15 Improved delivery includes
The prevalence of unprepared health systems partly stems expanding and strengthening primary health care to
from prioritising clinical care at the expense of promoting support health emergency preparedness and response—
healthy populations and societies. As a result, many social, for example, by removing user fees in health facilities,
political, and environmental determinants of health, making medical countermeasures (eg, diagnostics and
such as economic inequality, racism, gender inequity, therapeutics) free, scaling up a robust community health
and—increasingly—climate change, remain neglected workforce, and leveraging primary care data and social
throughout pandemic preparedness initiatives.24,25 Many insights.
reasons exist that account for this oversight, including
patronising modes of operation and a power imbalance of Emerging opportunities in pandemic
funding initiatives between high-income and low-income preparedness and response
countries, which often privilege global initiatives over the Aligning global health security and UHC capacities
priorities of local communities or less powerful nations. Although most countries have had difficulties in
The poor understanding of the foundational determinants sustaining an effective response over the duration of the
of health has been particularly evident in the absence of pandemic, initial studies suggest that health systems that
support for vulnerable populations, including a striking could effectively leverage both robust global health
paucity of social and economic protection policies at the security core capacities (eg, surveillance, laboratories, and
domestic level and of solidarity-based mechanisms to risk communication) and fundamental UHC interventions
provide affordable medical supplies at the international (eg, primary health care, affordable medicines and
level.26–28 supplies, accessible health facilities, and community
Such inadequacies disproportionately affected groups health workers) were often in a better position to protect
of individuals who were already marginalised, with their citizens against the social and economic impacts of
factors such as poverty influencing vaccine access the pandemic.6,35–37 For example, researchers in the USA
within countries and globally. In Brazil, low-income have argued that UHC could have averted more than
populations had reduced access to health care for 212 000 deaths and US$105 billion in just 2020 alone.38

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Mitigating wider determinants of health initiatives spanning health and finance ministries,
Countries found that they could not rely on isolated mechanisms that empower marginalised communities
technological innovations, standardised solutions, or through cooperation across regional blocs or low-income
fragmented health programmes when addressing long- countries, and civil society engagement) that diversify
standing gaps in emergency preparedness. The leadership to balance power and safeguard equity at all
COVID-19 pandemic has therefore incetivised fresh calls levels.48 Governments should also develop costed
to address the systemic political, social, environmental, National Action Plans for Health Security that accurately
and economic deter­minants and effects of public health estimate the resources necessary for pandemic
threats. Examples of this increasing awareness should preparedness and response and to allocate responsibility
include plans to mitigate the anthropogenic drivers of to relevant agencies and donor programmes.49 Ultimately,
zoonotic spillovers and other outbreaks (eg, climate these emerging opportunities are only achievable
change, changes in land use, and antimicrobial through renewed progress on UHC.
resistance) and invest in health systems that advance
both global health security and UHC. Strong investments Recommendations
in social security and safety nets as well as a primary Governance
health-care approach to pandemic preparedness and The Working Group on Strengthening WHO
response39,40 are required to effectively address these Preparedness and Response to Health Emergencies draft
determinants of health.41 report10 found consensus among member states that
many aspects of pandemic preparedness and response,
Developing equitable and inclusive pandemic such as equity (described as “the core of the breakdown in
preparedness and response mechanisms the current system”10), were not adequately addressed
Sustained political leadership and effective governance under the existing IHR and could instead be best enforced
were key factors in COVID-19 response and will con­ through new international legal instruments, such as a
tinue to influence future pandemic preparedness and pandemic treaty. In a promising shift from conventional
response. Good governance requires that health health security approaches, the working group called for
decision-making processes and institutions at national the need to “achieve universal health coverage and health
and international levels are accountable, transparent, system strengthening, which includes the enhancement
equitable, inclusive, participatory, and consistent with of primary health care, the health workforce and social
the rule of law.42,43 These principles can inform the protection”.10 Accordingly, negotiations for the IHR and
range of reforms to global governance for pandemic pandemic treaty have echoed these same calls to move
preparedness and response (eg, revisions to the IHR, beyond the status quo in health security.50 In this way,
global financing, and equitable mechanisms for global legal and policy reforms for pandemic preparedness and
public goods) currently being explored. Good governance response can reconceptualise solutions that advance both
can also be reflected in the standardised tools that global health security and UHC through resilient health
researchers use to assess countries’ performance in systems. The success of a new international instrument
responding to health threats.44 Many analyses have for pandemic preparedness and response to prevent the
shown the paucity of metrics to explain why some next health crisis will depend on whether it recognises
countries performed well and others poorly in controlling the gaps in health systems as key contributors to the
the COVID-19 pandemic; political and societal indicators exacerbation of health threats, and whether it responds to
could therefore be included in tools such as the Joint these challenges by mandating that traditional infectious
External Evaluations, which until now have relied heavily disease inter­ventions be implemented together with the
on biosafety and biosecurity when ranking countries’ multisectoral, comprehensive, and proactive interventions
preparedness and readiness. made possible by UHC.
Holistic and modernised approaches to health Furthermore, the inability to achieve equity should be
emergency prevention, preparedness, response, and remedied through legal reforms based on a human
recovery include being equipped to support equitable rights approach.51 Such an approach includes ensuring
and resilient health systems that can promote essential equitable access to medical counter­ measures and
public health functions together with emergency risk affordable medicines and supplies through the full use
management, and mitigate market failures in research of flexibilities and waivers for public health, such as
and development of medical countermeasures. those under the Agreement on Trade-Related Aspects
Global health security efforts could actively address gaps of Intellectual Property Rights.52,53 Through diplomatic
in health legislation, incorporating the protection of and legislative means, an instrument for pandemic
public health and human rights, and enshrining preparedness and response and more enforceable IHR
accountable and transparent decision making consistent amendments provide novel opportunities to codify and
with the rule of law.45–47 These efforts could be prenegotiate obligations and mechanisms for equity in
strengthened by bold and inclusive institutional the development and distribution of vaccines,
arrangements (eg, multisectoral, whole-of-government diagnostics, personal protective equipment, and

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treatments in low-income and middle-income countries Financing

before, during, and after health emergencies. Several initiatives developed in the wake of the COVID-19
International and intranational equity can only be pandemic have drawn particular attention to the absence
assured through multistakeholder and multisectoral of sustainable financing for pandemic preparedness and
engagement at all stages of policy development. Any response. World leaders should maximise resources and
international law reform should align with humanitarian avoid duplicative efforts by integrating investments in
principles and ensure meaningful participation of health systems to support both global health security and
marginalised groups in decision making (eg, women, UHC. All financial mechanisms intended to support
refugees, migrants, displaced or homeless populations, pandemic preparedness and response should thus include
and racial minorities). Clear national and subnational a core component of financing for community-based
strategies for intersectional and rights-based approaches health systems, particularly through primary health care.40
should therefore be institutionalised across global health The World Bank-based Financial Intermediary Fund for
security and UHC programmes.27,54 Pandemic Prevention, Preparedness and Response, also
Broadening political leadership in pandemic known as Pandemic Fund, has been developed to mobilise
preparedness and response governance—for example, health security investments such as global surveillance,
through the proposed Global Health Threats Council and provision of emergency countermeasures, and funding
the UN High-Level Meeting on pandemic prevention, for research and development in pandemic prevention.
preparedness, and response—might not only enhance However, this framing largely neglects the basic health
accountability at the highest levels of power but also help systems components required to comprehensively
incetivise political will and investments in health systems address public health threats, including robust primary
strengthening at national and subnational levels. These health care, well trained and supported local and
efforts should be reinforced by equitable institutional community health workers, interoperable data systems,
arrangements and governance of power relations (such as and accessible health centres.11 Accordingly, the Pandemic
gender parity and diverse representation), cognisant of the Fund should mandate a minimum base amount of
role of civil society together with both public and private financing for essential public health functions that
sectors, and supported by legislative review and reform.55 support the health workforce and maintain routine health
Reimagined global and national accountability for services in pandemic preparedness and response. This
pandemic preparedness and response should involve non- approach would avoid the pitfalls of the now defunct
state actors and take an integrated approach, such as World Bank Pandemic Emergency Financing Facility—a
through independent reviews (eg, the Global Health financing mechanism that was criticised for being too
Security Index or the Universal Health and Preparedness focused on managing rather than preventing epidemics in
Review) that draw on the example of the Universal low-income and middle-income countries.62 Furthermore,
Periodic Review set up by the UN Human Rights Council. the fund should foster coherence across the pandemic
Additionally, assessments could be pursued together (eg, preparedness and response architecture by prioritising
jointly conducting Joint External Evaluations and Service investments identified through pandemic treaty
Availability and Readiness Assessments).56 Crucially, these negotiations, IHR amendments, and WHO’s health
independent reviews and assessments should consider emergency preparedness and response framework.1
the spectrum of social, political, and commercial The Global Health Threats Board has been proposed to
determinants of health. By strengthening international provide systemic global financial oversight to enable
solidarity via the facilitation of cross-national learning, effective and efficient resourcing of pandemic prevention,
such independent evaluations could offer practical detection, and response capacities. This mechanism
insights on ways forward to address context-specific public and the governance for the Pandemic Fund should
health needs and build healthy societies.57 meaningfully involve civil society and community stake­
New legal governance instruments should not be holders in its decision-making architecture, providing
conceived and developed by high-income countries and cross-sectoral health and social science perspectives to
then imposed on low-income countries. To ensure ensure timely, proactive, and systems-wide support during
comprehensiveness, appropriateness, and fairness, all health emergencies. Clear indicators and targets on equity
countries should be able to meaningfully contribute and resilience should accompany this mechanism to
to the development of pandemic preparedness and protect both lives and livelihoods. The Global Health
response reforms.58–60 With ongoing vaccine inequity, the Threats Board should also operationalise pandemic
emergence of new SARS-CoV-2 variants, and travel preparedness and response investments through
restrictions that disproportionately affect low-income and alignment with broader SDGs (eg, SDG 3 [gender
middle-income countries, international organi­ sations equality], SDG 8 [decent work and economic growth],
and high-income countries have a special obligation to SDG 13 [climate action], and SDG 17 [partnerships for the
prevent and mitigate direct, indirect, and discriminatory goals]) to ensure global health security investments
exclusion of stakeholders from low-income countries in advance, rather than potentially undermine, progress
pandemic preparedness and response negotiations.61 towards health and wellbeing.6,15,63

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Fostering global solidarity, such as by funding the multisectoral representatives at the national level,
common goods for health, is an overlooked role of including ministries, multilateral offices, and civil society;
global health security financing. Common goods are these teams could be established as standing coordination
interventions that require collective financing and include bodies and integrated within national IHR focal points
investing in essential public health functions, building to support prevention, preparedness, response, and
local health systems, and incetivising UHC.64 To ensure recovery. Such an approach can help maintain essential
the provision of common goods for health, WHO health services, ensure sustainable workforce surge
member states need to support proposals for a substantial staffing through training and remuneration,69 empower
increase (at least 50%) in assessed contributions to WHO, low-income and middle-income countries in bilateral or
and provide the organisation with non-earmarked multilateral negotiations, and harmonise emergency and
funding, as proposed by the Working Group on routine data to guide decision making.70–72
Sustainable Financing.65 All efforts should be made to Follow-on iterations of the ACT Accelerator should
ensure that these funds come from equitable apply a holistic definition of equity beyond merely
contributions of high-income countries, donors, and considering disparities at the nation-state level between
private sector partners, and that clear enforceability high-income and low-income countries. This means
mechanisms exist for all participating stakeholders. taking a human rights approach to in-country disparities
Pandemic preparedness and response financing exacerbated by emergencies, such as mitigating gender
should contribute towards pooled funding to sustain barriers and inequities due to socioeconomic status,
health capacities through primary health care, because enforcing collection of disaggregated data that explicitly
outbreaks begin and end at the local level; its design track intersectional inequities across vulnerable com­
should thus be centred on community health workers munities, and safeguarding freedom of press and speech
and services.66 Regionally, these people and services can to ensure accurate and timely health information during
support the expansion of affordable and accessible emergencies.66,73,74 Such efforts should be affirmed and
essential medicines and supplies through pooled closely monitored by the newly-proposed WHO Global
procurement mechanisms, such as the Strategic Fund of Health Emergency Council.
the Pan American Health Organization, and mobilise Pandemic preparedness and response initiatives, such
financial resources for social protection during health as the Global Health Security Agenda, should leverage
emergencies. Domestically, removing user fees UHC and social protection to support traditional health
at health facilities, delinking health insurance from security core capacities.75–77 Other high-profile, donor-
employment, and funding health promotion are crucial driven global health security programmes (eg, the US
factors that could further enable the operationalisation of President’s Emergency Plan for AIDS Relief, the Global
UHC to better support broader preparedness and Fund to Fight AIDS, Tuberculosis and Malaria, or the
response financing.67,68 Coalition for Epidemic Preparedness Innovations) should
promote health systems resilience in low-income
Supporting initiatives countries and fragile and conflict-affected states, in
Programmes designed to address health security accordance with self-identified community and national
challenges have been heavily influenced by the COVID-19 priorities.78,79 Resilience can be further achieved by
pandemic. As pandemic preparedness and response strengthening primary health care as a way to foster
initiatives are redesigned to better cope with future greater alignment across pandemic preparedness and
health threats, it is key they incorporate UHC principles response spending and objectives. The governance and
by scaling up people-centred health systems. frameworks used to guide future health emergency
The ACT Accelerator attempted to leverage its Health response mechanisms should be rooted in whole-of-
Systems and Response Connector pillar to better support society and multisectoral structures, including diverse
in-country integration and delivery of COVID-19 civil society and community-led organisations from low-
countermeasures, such as vaccines, diagnostics, and income countries, to achieve equity and support long-
therapeutics.12 However, the pillar was developed too late, term goals for both global health security and UHC, as
received too little funding, and struggled to effectively suggested by the Global Preparedness Monitoring Board.80
serve as a supporting foundation for the other pillars,
such as the COVID-19 Vaccines Global Access for Conclusions
equitable vaccine procurement. Furthermore, the strategy In the wake of the COVID-19 pandemic, there have
took a myopic view of the role of health systems, focusing been multiple reports, reviews, and proposed initiatives.
on personal protective equipment for health workers However, the global response has been debilitated by
while neglecting other crucial interventions, such as an alarming shortage of timely action and investment.
accessible health facilities and proactive community Although the push towards global health security has
engagement. Future mechanisms should leverage the helped make the case for global cooperation to counter
Health Systems and Response Connector’s model of public health threats, such efforts have largely neglected
country coordination teams, which consisted of to consider how health systems function within

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countries. Health systems designed for UHC have been Vice Chair of the Board of Directors for Women in Global Health and a
shown to support communities more equitably through representative of the Platform for ACT-A Civil Society and Community
Representatives.
primary health care. Future pandemic preparedness
and response mechanisms should prioritise health References
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